Using Positive Deviance to reduce medication errors in a tertiary care hospital

作者：Ferracini Fabio Teixeira; Marra Alexandre R^*; Schvartsman Claudio; Pavao dos Santos Oscar F; Victor Elivane da Silva; Marques Negrini Neila Maria; Borges Filho Wladimir Mendes; Edmond Michael B

来源：BMC Pharmacology & Toxicology, 2016, 17(1): 36.

DOI：10.1186/s40360-016-0082-9

• Patient safety
• Medication errors
• Prevention

Background: The number of medication errors occurring in healthcare is large and many are preventable. To analyze medication errors and evaluate whether Positive Deviance is effective in reducing them.
Methods: The study was divided into three phases: (2011-Phase I, control period; 2012 - Phase II, manager intervention, and 2013 - Phase III, frontline healthcare worker intervention). In Phases II and III, the Positive Deviance method (PD) was used to mitigate medication errors classified as "C" and higher according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The errors reported were compared across the three study phases, as well as by the location of the hospital unit, shift, cause, consequence, and the professional associated with the error.
Results: A total of 4013 reported medication errors were analyzed. The largest number of errors occurred at the time the medications were administered, accounting for 35.5 % of errors in Phase I; 43.1 % in Phase II, and 55.6 % in Phase III. Nursing staff was most commonly associated with errors; 46.4 % of errors in Phase I, 48.5 % in Phase II, and 58.7 % in Phase III. With each intervention, a decrease was observed in the reported error rate of 0.12 (CI 95 %, 0.18 to 0.07).
Conclusion: Positive Deviance proved to be effective, primarily when healthcare professionals who were involved in errors participated, as was observed in Phase III of this study.

• 出版日期2016-8-7